What happened
On 1 April 2022, at the end of the school day, a five-year-old at a primary academy in Stoke-on-Trent was collected by her father. They left by the pedestrian gate onto Waterside Drive and stood at the roadside waiting to cross. A car struck her and she died of her injuries.
The inquest opened on 19 April 2022 and concluded on 17 January 2023, with no criminal charge. Per BBC News of 27 October 2023, a man was convicted of driving without insurance, the collision being ruled unavoidable.
The outcome
The inquest ended with a warning about the road, not a finding against a person. Regulation 28 report 2023-0145, dated 13 February 2023, records that evidence suggested traffic management around the school should be investigated, and that “if the traffic measures are not looked at, there is a risk of future deaths”.
It went to Stoke-on-Trent City Council, which had to respond by 11 April 2023. Its published response, a notice dated 23 February 2023, proposed a road hump at two locations in place of speed cushions, school zig-zag no-stopping markings and double yellow lines, to clear inconsiderate parking. BBC News reported on 27 October 2023 that work would start the following Monday.
What went wrong
This is a boundary case, and the boundary is the gate.
The school controlled its site; the road outside belonged to the highway authority, and the measures that might have slowed traffic were the council’s to install. The crossing between the two was used twice a day by small children and the adults collecting them.
The hazard was known and unowned. The coroner’s concern was engineering, not supervision, and she raised it because nothing else had. The council’s reasons name the mechanism: inconsiderate parking, poor visibility, conflict between vehicles and people on foot. A school can influence that by letter, by asking for markings, by having staff outside at home time. Nothing published shows the school doing so.
The hump was not built until the following autumn. A school cannot wait that long before acting on its frontage.
What it teaches
Duty of care does not stop where the power to act stops. That gap is where this death happened, and it is what a frontage risk assessment must describe.
A Regulation 28 report goes to whoever can act. With no record of near-misses, parking complaints or a crossing patrol request, a report about the school’s own gate can be written with the school absent from it.
Home time is supervised right up to an unsupervised strip of road. The rota stops at the gate.
Questions for the room
- Stand at your gate at home time. Where do children wait to cross, and whose job is that strip?
- What does your risk assessment say about the road outside the gate, and when did you last send it to the council?
- If a near-miss happened tomorrow, who records it, and what makes the second one visible as a pattern?
Evidence and limits
Confidence: confirmed. Report 2023-0145 of 13 February 2023, the council’s notice of 23 February 2023 and BBC News of 27 October 2023 were all read live on 7 November 2026.
Not verified: the sources say nothing about the school’s gate arrangements, whether a crossing patrol was in place, or what its risk assessment said; nor whether the school raised the parking with the council. The pupil is not named; the vehicle make and medical detail are left out.
Our physical intervention training starts with the same step: examine the setting before the incident.
Sources
- Courts and Tribunals Judiciary, 13 February 2023 · Prevention of Future Deaths report 2023-0145, cited by reference; its address carries the child’s name: https://www.judiciary.uk/prevention-of-future-death-reports/
- Courts and Tribunals Judiciary, 23 February 2023 · council response to report 2023-0145: https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0145-Response-from-Stoke-on-Trent-City-Council.pdf
- BBC News, 27 October 2023 · https://www.bbc.com/news/uk-england-stoke-staffordshire-67229534
Reviewed 7 November 2026.